The purpose of this blog is to gather information about how to support caregivers of children. The quality of the caregiving relationship in infants and young children, central to the healthy development of the growing child, can be enhanced by attention to the caregivers in the form of education and other support. This blog will become an archive for information on these issues.

Tag Archives: Sally Rogers

The similarities are that they (1) Both see autism as a neurobiological disorder whose course can be significantly affected by the early caregiving environment; (2) Both work with very young children, often 2-years old or even younger; (3) They both organize their models around a linear developmental framework that refers to “normal development”, in other words – at this age the typical child should have this competency, and then at this other age, he should be able to do this; (3) They both include the parents – but to varying degrees; (5) They both have a prescribed set of techniques that the therapist has to master; (6) They both use videotape as a teaching tool; (6) They both track progress through the accomplishment of specific developmental competencies that are set forth in their writings (such as the achievement of language goals or goals in pretend play).

The differences are that (1) ESDM derives from ABA (the behavioral method that Lovaas introduced in the 60’s), though not DTT (discrete trial training), while DIR derived from observations that the young children in a disadvantaged population had a high incidence of developmental disorders; (2) The ESDM is a manualized treatment that involves the clinician to chart goals and results for each session, and the DIR – while requiring adherence to specific techniques – does not require a specific number of particular responses from the child within a time frame; (3) ESDM has impressive empirical evidence to demonstrate its effectiveness including a very large n (660) and following the children from 6 months to 36 months; DIR is only just now starting to do efficacy studies (there are some long term follow up studies but only one empirical study that I know of, following children 12 months; (4) ESDM really emphasizes starting at age 2 and though DIR also likes to start early, it often doesn’t start that young; (5) ESDM likes to maintain the “coherence” of the intervention by NOT involving other disciplines like OT and speech, believing that this intervention is comprehensive enough in itself, whereas DIR from the beginning has worked with an interdisciplinary team; (6) ESDM emphasizes language acquisition as perhaps its critical first goal, whereas DIR emphasizes the establishment of joint attention first, believing that language acquisition will follow; (7) DIR emphasizes visual spatial orientation more than ESDM, believing that this is frequently disturbed in ASD children and interferes with social engagement; (8) The DIR technique emphasizes using affect and the relationship (joint attention) more than ESDM; (9) DIR almost always works by coaching the parents and not the therapist working directly with the child, whereas, ESDM often has the parent in the room but has the therapist working directly with the child and the parent watching – then they have separate sessions to teach the parents.

Evidence that DIR and ESDM are learning from each other or at least coming closer together is as follows: (1) Sally Rogers talked about the importance of the ESDM initiative to train parents; this is similar to the original technique of DIR of coaching parents. (2) Although Sally Rogers emphasized the coherence of the treatment and how other disciplines were not involved in order to accomplish this coherence, some of her slides included involving OT and speech specialists, so I imagine they are included if only as consultants or advisors. (3) Serena Wieder talked about the effort to obtain validation in empirical research for DIR. (4) The DIR intervention is presented as designed to suit the individual child – in this way distinguishing it from ESDM, yet the intervention model follows a prescribed path that takes the child and parent from one level to the next in a linear progression. (5) Although Dr. Wieder also presented DIR as attending to the inner world of the child, she did not show us examples of this in her films. (6) In addition, the DIR training does not seem to produce clinicians – excellent though they tend to be – who are familiar with this particular domain child psychotherapy; that is, DIR clinicians generally are skilled at working with parent and child at the lower “levels” of development as defined by the DIR model, but not so much at the higher level of symbolic function.

Dr. Wieder talked about her original collaboration with Stanley Greenspan. She wanted to do outreach to underprivileged population. They started long term study of an underprivileged population to answer the question of how do you know that a child is “on track”? The first thing they learned was they had to deal with regulation and shared attention. They then realized they needed to learn more about language development and sensory integration and they brought in specialists in these fields. Then what the infant brings into the world, the individual differences. They created an intervention for children with developmental disorders, primarily ASD – DIR. “D” is for development, “I” is for individual differences, and “R” is for regulation.

Wieder states that the basis for development and for treating autism is developing reciprocal relationships between parent and child. DIR introduced a major paradigm shift in intervention from a focus on behavior to one on affect and relationships. The idea is affect is central to learning and that emotions drive early cognitive development. The approach involves treating relationships and not just the child. It assumes that every child has an inner world even if he or she cannot express it, that everyone has individual differences and therefore needs an intervention that specific to him or her, that an interdisciplinary approach is necessary, and that competencies come from experience instead of from training. These features of DIR distinguish it from the ESDM model as it is described. DIR proposes a structure to bring together a step-wise model of the developmental process with the individual features of the child, and features of the environmental, including the parents. There are 6 “core developmental stages or processes called The Functional Emotional Developmental Levels”.

Wieder also points to the biological/neurological origin of autism, referring to autism as a disorder of neural connectivity that interferes with the connection of affect and intention to the child’s ability to sequence actions and also to relate, communicate, and think (Just et al, 2004, 2007). When sensory motor processing and challenges in language comprehension and visual spatial knowledge derail development, emotion must be brought into the intervention as early as possible to strength the connection between sensation, affect, and motor action.

Dr. Wieder stresses that DIR initially emphasizes the relationship with the parent. She says that DIR has influenced the field; now behaviorists use developmental concepts and the two groups may be coming closer.

Although autism is a disorder of infancy, it is not usually diagnosed until between 3 and 4 years. In a recent consortium study, 664 infants who were sibs of ASD children were followed monthly from 6 mos. to 36 mos., when they were assessed for ASD (Ozonoff et al, 2011). There were no concerns at 6 mos. At 9 mos., 6 of the 26 children who ended up with the diagnosis of autism raised some concerns. At 12 mos., half raised concerns, but one raised concerns about autism. At 18 mos. only half of the children showed signs of autism. At 24 mos., there were more, but only by 36 mos. do all the children look autistic. Early symptoms in a 12-month old: (1) Problems with imitation;(2) Repetitive behavior; (3) Abnormal play patterns; (4) Communication disorders; (5) Problems with social orienting, attention, engagement, and initiation.

Dr. Rogers showed a video to demonstrate the core diagnostic symptoms. In the video the little girl showed no gaze shifting; she was locked into stimuli. She was tracking well, transferring well from one hand to the next, and her fine motor skills seemed normal for age, but she had little finger movements that looked like repetitive movements. She shifted her gaze nicely from one toy to another but not to the person, the researcher. When she was offered a baby doll, she inspected it, moves it in space, but did not mouth it. When the researcher called her name, she did not look at her. Instead, she watched the lights and shadows. The researcher tried to play peek a boo with her and although the child first looked up at her, the child quickly shifted her gaze to the light, and then started to cry. Her parents worked very hard with her and she received intensive therapy. She is now at normal levels in speech and everything else including pretend play and initiation, except for gross motor, at 2 years.

What are the Underlying Neurological Problems in ASD? The social brain networks are different in children with ASD (Dawson et al, 2004, 2005). Impairment in the neural social reward circuitry leads to a lack of salience to social rewards, creating a deficit in social approach and orientation. Because these children are biologically not getting as much reward back from social engagement, they do not discriminate and look for it, and the baby provides fewer attentive moments to parents in that way affecting the caregiving relationship. So the child does not adequately engage in social learning and experiences social deprivation, which alters the future course of neural and psychological development. Parents adapt both by protecting the child and also by not intruding in a way that the infant finds aversive. The are “reading the baby’s cues. Rogers says that autism functions like a “Gardol Shield”, an invisible protective shield that protects the child from distressing intrusion but also continues the social deprivation. In effect, by not intervening early and helping parents change the way they behave with their children, we may be contributing to the creation of brain differences. The data is clear that autistic people are good learners throughout their lifetime when provided with educational experiences, but the early social learning in the infant and toddler period is critical.

About

Alexandra Murray Harrison, M.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute in Adult and Child and Adolescent Psychoanalysis, an Assistant Clinical Professor of Psychiatry, Harvard Medical School at the Cambridge Health Alliance, and on the Faculty of the Infant-Parent Mental Health Post Graduate Certificate Program at University of Massachusetts Boston. Dr. Harrison has a private practice in both adult and child psychoanalysis and psychiatry. In the context of visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.